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G.J.B.B., VOL.4 (2) 2015: 191-194
ISSN 2278 – 9103
ASSESSMENT OF HOMOCYSTEINE LEVEL IN PLASMA OF IRAQI WOMEN
WITH POLYCYSTIC OVARY SYNDROME AND INSULIN RESISTANCE
Jasmine S. Hasan1, Alia H. Ali1, Muhammad-Baqir M-R. Fakhrildin2
2
1
College of Science for Women, Baghdad University;
High Institute for Infertility Diagnosis and Assisted Reproductive Technologies, AL-Nahrain University, Baghdad, Iraq
ABSTRACT
Polycystic ovary syndrome (PCOS) is a common endocrine disorder which affects women at reproductive age. This study
was aimed to detect homocysteine level in women with polycystic ovary syndrome. The present study was carried out for
(51) PCOS women and (10) healthy women as controls at High Institute for Infertility Diagnosis and Assisted
Reproductive Technologies/AL-Nahrain University, from February to August, 2014. Homocysteine test and OGTT were
performed for all women. Age and BMI were recorded for all subjects and duration of infertility recorded for infertile
PCOS women. Significant increment (P<0.05) in homocysteine level was observed in obese PCOS group with duration of
infertility >9 years, but the differences in homocysteine was not significant (P>0.05) between PCOS women and controls,
and among PCOS subgroups. Significant increment (P<0.05) in OGTT was recorded in obese patients when compared
with controls. The present study concluded that homocysteine elevation in PCOS women related to obesity and insulin
resistance. Also, it has a relation with duration of infertility.
KEYWORDS: Polycystic ovary syndrome, Homocysteine, insulin resistance.
may contribute to the risk of cardiovascular disease[11].
PCOS diagnose by the presence of two out of three which
include[12]: 1.Oligomenorrhea or anovulation; 2.Clinical
signs which include hirsutism and acne, biochemical signs
of hyperandrogenism which include the elevation of free
testosterone or testosterone; 3.Polycystic ovaries confirms
using ultrasound scan which is clear the presence of 12 or
more follicles in each ovary measuring 2-9mm in
diameter. Therefore, the aim of this study is to detect
homocysteine level in PCOS women with insulin
resistance which was detected by using OGTT.
INTRODUCTION
Polycystic ovary syndrome (PCOS) is a common
endocrinopathy affecting 6-10% women of reproductive
age[1]. PCOS had been initially described in 1844 by
Chereau and Rokitansky[2]. PCOS may occur as high as
30% in women suffering from secondary amenorrhea,
75% in women suffering from oligomenorrhea, and 90%
in women with hirsutism[3]. About 50% of PCOS patients
are obese or they have a greater risk of overweight,
obesity, and central obesity[4]. Also, many PCOS women
may have high increased risk of cardiovascular disease
(CVD) and endometrial cancer[5]. Additionally, the late
complications of PCOS, such as primarily diabetes,
dyslipidemia, and CVD seem to be connected to insulin
resistance[6], and the multiple risk factors for CVD in
young women with PCOS including; type 2 diabetes
mellitus (T2DM), metabolic syndrome (MS), abdominal
obesity, dyslipidemia, and hypertension[7]. There are
different risk factors for cardiovascular disease (CVD)
have been studied in women with PCOS, one of them is
homocysteine[8]. Homocysteine (HCY) is an amino acid
containing thiol, which is an independent risk factor for
CVD[9]. It is an intermediate product of methionine
metabolism, and homocysteine itself metabolized by two
pathways: the re-methylation pathway, which regenerates
methionine, and the transsulfuration pathway, which is
degrades homocysteine into cysteine and then taurine[10].
In women with PCOS, the mean serum homocysteine
concentrations are increased, which the most variables that
influence the homocysteine concentration were taken into
account and the higher homocysteine levels may associate
with hyperinsulinemia in these patients. Additionally, in
women with PCOS, together with other risk factors like
hyperinsulinemia or dyslipidemia, homocysteine elevation
MATERIALS & METHODS
This study was carried out at the laboratory of Hormonal
and Biochemical assays of High Institute for Infertility
Diagnosis and Assisted Reproductive Technologies / ALNahrain University from 1 February to 1 August, 2014.
From the total of 61 women with age range 17-49 was
studied, 51 women were suffering from PCOS, and 10
healthy women were considered as controls to compare
with PCOS's women. Blood samples (about 5mL) were
collected from each fasting woman in the morning and 75
gm of glucose loaded in 400-500 ml of water and given to
the subjects. From the collected blood in previous step, 4
mL of it was transferred to gel and clot activator tube and
incubated for 10 minute in incubator at 37ºC to coagulate,
and serum separated by centrifuge and freezing in -4 ºC,
but the remaining blood (1mL) transferred to tube with
EDTA as an anticoagulant to separate plasma. Then the
samples centrifuged and the plasma stored at -20°C which
prepared for homocysteine test. OGTT test was performed
after 30, 60, and 90 minute after glucose loading. The
principle assay of homocysteine test employs the
quantitative sandwich enzyme immunoassay technique by
191
Homocysteine level in plasma of Iraqi women
using ELISA kit of CUSABIO (China). The normal value
of laboratory homocysteine is range from (0.4-3 nmol/ml).
Patients considered with hyperhomocysteinemia with
homocysteine level >3 nmol/ml. GTT was performed
using glucose MR kit of Linear (Spain). The normal value
of OGTT is <140 mg/dl, OGTT between 140-199mg/dl
refer to impaired glucose tolerance, and its considered
diabetic if OGTT ≥ 200 mg/dl [13]. Body mass index (BMI)
was measured for all subjects by dividing weight into
kilogram on height in meter square. BMI value indicates
for body weight, subjects with BMI 18.5-24.9 Kg/m2
considered normal weight, with BMI 25-29.9 Kg/m2
considered overweight, and with BMI ≥ 30 Kg/m2
considered obese. The duration of infertility recorded for
all infertile PCOS patients.
Statistical analysis was performed using Statistical
Package for Social Science (SPSS); version 20. The
differences among more than two groups were assessed by
using ANOVA table- Duncan test with means and
standard error of means while the comparison between
two groups were assessed by using F test. The confidence
level has been chosen as 95% and P value <0.05 was
considered as significant.
RESULTS
There was a comparison of parameters including; age,
BMI, GTT (FBS and OGTT), and homocysteine levels
among PCOS women and control group. As shown in
table (1), there were no significant differences (P>0.05) in
the age, BMI and in GTT (FBS and OGTT) between the
two groups. Also, in comparison to homocysteine level
between PCOS group and control subjects. No significant
differences (P>0.05) in homocysteine level were observed
between the two groups.
TABLE 1: Comparison in parameters between
Control (n=10) PCOS (n=51)
Parameters
16.40%
83.60%
P value
Mean ± S.E
Mean ± S.E
Age (Years)
33.10±3.139
28.53±1.060
NS
BMI (Kg/m2)
26.99±1.746
30.0±0.902
NS
FBS (0 time) (mg/dl)
82.48±1.768
95.77±3.614
NS
R1BS(30min)(mg/dl)
136.2±2.928
155.62±6.136 NS
R2BS(60 min)(mg/dl)
125.38±5.438
155.39±8.389 NS
R3BS(90 min)(mg/dl)
115.68±5.407
139.49±7.671 NS
HCY (nmol/ml)
3.69±1.076
5.04±1.620
NS
PCOS women and control group
PCOS=polycystic ovary syndrome, BMI=Body mass index, FBS = fasting blood sugar, R1BS=Reading 1 blood sugar,
R2BS= Reading 2 blood sugar, R3BS= Reading 3 blood sugar HCY=homocysteine, NS= non significant
As observed in the table (2), a comparison of parameters
among PCOS subgroups according to BMI included;
women with normal Weight (BMI 23.38 kg/m2), as
contrast PCOS women with overweight (BMI 27.30
kg/m2), PCOS obese groups (BMI 35.92kg/m2), and
control group. However, no significant differences
(P>0.05) were assessed at the age among the four groups.
Highly significant differences (P<0.05) were observed in
BMI of obese PCOS than normal weight PCOS,
overweight PCOS and control group. Also, there was
higher significant differences (P<0.05) in overweight
PCOS than normal weight PCOS group. Normal weight
PCOS were had lower value of BMI than control group,
but there were no significant difference (P>0.05) in BMI
between overweight PCOS and control group.
TABLE 2: Comparison in parameters among PCOS group (normal weight, overweight, and obese) and control group
control
PCOS Normal PCOS
PCOS Obese
Parameters
(n=10)
weight(n=13)
Overweight (n=16) (n=22) 36.06%
16.40%
21.31%
26.23%
Mean ± S.E
Mean ± S.E
Mean ± S.E
Mean ± S.E
Age (Years)
33.10±3.139a
28.46±2.712 a
30.06±1.764 a
27.45±1.403 a
BMI (Kg/m2)
26.99±1.746 b 23.38±0.275 A
27.30±0.304 b
35.92±1.126 a
FBS (0 time) (mg/dl)
82.48±1.768 b 90.57±4.174 ab 87.71±2.529 ab
104.70±7.487 a
R1BS(30min)(mg/dl)
136.20±2.98 b 140.69±9.22 ab 147.04±7.367 ab
170.67±11.43 a
R2BS(60min) (mg/dl)
125.38±5.48 a 125.29±10.78 a 151.89±11.73 ab
175.73±15.73 b
R3BS(90min)(mg/dl)
115.68±5.47 b 119.27±9.16 ab 131.22±10.23 ab
157.45±14.67 a
HCY(nmol/ml)
3.69±1.076a
3.21±0.815a
7.90±4.866 a
4.04±1.237 a
Different letters mean significant (P<0.05)
PCOS=polycystic ovary syndrome, BMI=Body mass index, FBS = fasting blood sugar, R1BS=Reading 1 blood sugar,
R2BS= Reading 2 blood sugar, R3BS= Reading 3 blood sugar, HCY=homocysteine
As for the GTT, there were significant increased (P<0.05)
levels in FBS, R1BS, and R3BS of obese PCOS than
control group. In contrast, non significant differences
(P>0.05) were noticed in levels of FBS, R1BS, and R3BS
among normal weight PCOS, overweight PCOS, and
control groups. Also, there were non-significant
differences (P>0.05) in levels of FBS, R1BS, and R3BS
among normal weight PCOS, overweight PCOS, and
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G.J.B.B., VOL.4 (2) 2015: 191-194
ISSN 2278 – 9103
obese PCOS group. Significant increment (P<0.05) was
observed in R2BS levels in obese PCOS when compared
with control group. Also, significant elevation (P<0.05)
was observed in R2BS levels of obese PCOS as compared
to normal weight PCOS group. Non-significant differences
(P>0.05) were assessed in R2BS among normal weight
PCOS, overweight PCOS and control group. Additionally,
there was no significant difference (P>0.05) between
obese PCOS and overweight PCOS groups. Another
comparison among these groups was assessed in
homocysteine levels as illustrated in the same table. No
significant differences were (P>0.05) recorded among
PCOS subgroups and control subject in homocysteine
levels. A comparison among infertile PCOS subgroups
according to their duration of infertility including; group
(A) with duration of infertility range from 1-4 years; group
(B) with duration of infertility range from 5-8 years; and
group (C) with duration of infertility 9 ≤ years as shown in
the table (3). From the same table, non-significant
differences (P>0.05) were recorded in the age and BMI
among the three groups, but significantly differences
(P<0.05) were reported for duration of infertility among
the three groups. As for GTT compared among PCOS
subgroups (table 3). Significant differences (P<0.05) in
FBS levels were observed between groups (B) and (C),
which was higher in group (C) than group (B) while nonsignificant differences was noticed (P>0.05) for the group
(A) as compared to both group (A) and (B). Significant
elevation (P<0.05) in the levels of R1BS were observed in
the group (C) when compared to the group (A) and group
(B). While no significant differences (P>0.05) were
recorded between groups A and B. In addition, R2BS
levels were significantly increased (P<0.05) in the group
(C) than the group (A). However, non-significant
differences (P>0.05) were observed in R2BS levels of
group (B) with the group (A) and group (C). Moreover, no
significant differences (P>0.05) were observed among the
three group in R3BS levels. Concerning to the comparison
in HCY levels among infertile PCOS subgroups according
to their duration of infertility, significant (P<0.05) levels
of homocysteine was observed in the group (C) when
compared with the group (B), but not significant (P>0.05)
with the group (A). Also, no significant differences
(P>0.05) in homocysteine levels were assessed between
the group (A) and group (B).
TABLE 3: Comparison in parameters among PCOS subgroups according to their duration of infertility
Group(A)(1-4
Group(B)(5-8
Group(C)
Parameters
years)(n=23)
years)(n=20)
( ≥9years) (n=8)
45.10%
39.22%
15.68%
Mean ± S.E
Mean ± S.E
Mean ± S.E
Age (Years)
27.70±1.780a
28.65±1.632 a
30.63±1.889 a
BMI (Kg/m2)
29.62±1.381a
29.57±1.096 a
32.29±3.286 a
D. of infertility (years) 2.11±0.253 a
5.95±0.246 b
11.38±0.680 A
FBS (0 time) (mg/dl)
94.41±3.216 ab 90.93±2.303 a
111.76±20.481 b
R1BS(30min)(mg/dl)
150.13±6.475a
144.55±6.416 a
199.06±27.032 b
R2BS(60min) (mg/dl) 141.67±7.726a
156.13±9.929 ab 192.99±41.432 b
R3BS(90min)(mg/dl)
132.25±7.657a
136.88±8.538 a
166.81±39.040 a
HCY (nmol/ml)
4.17±1.027ab
3.03±0.913 a
12.58±9.716 b
Different letters mean significant (P<0.05)
PCOS=polycystic ovary syndrome, BMI=Body mass index, D= Duration of infertility, FBS = fasting blood sugar,
R1BS=Reading 1 blood sugar, R2BS= Reading 2 blood sugar, R3BS= Reading 3 blood sugar, HCY=homocysteine
et al., they concluded that obesity is not an independent
risk factor to increase plasma homocysteine levels in
PCOS women, and they added that HCY level increased in
non-obese PCOS women in comparison to obese ones [16].
Moreover, homocysteine level significantly elevated in
PCOS subgroup (C) with duration of infertility >9 years
(table 3), where they had insulin resistance according to
higher OGTT, this result in concordance with Hemati et
al. They concluded significant correlation between insulin
resistance and homocysteine[17]. Furthermore, PCOS
subgroup (C) with proportion (15.68%) were obese (BMI
>30 kg/m2). In this case, hormone resistin may play an
important role in insulin resistance[18], therefore there was
a relation between obesity and homocysteine level and this
result agreement with[19]. Also, higher GTT in obese
subgroups refers to insulin resistance that may due to
resistin hormone leading to insulin resistance, while serum
resistin level increase in the presence of obesity in mice,
an anti-diabetic agent rosiglitazone decreased levels and
that administration of recombinant resistin to mice caused
impairment in glucose tolerance and insulin effect[18].
DISCUSSION
When PCOS women divided into subgroups according to
BMI values (Table 2), higher prevalence of PCOS women
(36.06%) of females were observed had higher BMI
(BMI=35.92±1.126 kg/m2) and considered obese, about
26.23% of females with PCOS had mild higher BMI
(BMI=27.30±0.304 kg/ m2) and considered overweight,
and about 21.31% of subjects with PCOS considered
normal weight with (BMI= 23.38± 0.275 Kg/m2) that
means PCOS case frequently higher in overweight and
obese women, and the obesity play an important role in
pathophysiology of
this syndrome[14]. Higher BMI
2
(BMI≥30 kg/m ) value is a marker for obesity which is a
common finding in women with PCOS, but it is not part of
the diagnostic criteria[15]. Non-significant differences in
HCY levels for obese and overweight patients in
comparison to PCOS subgroups and control subjects in
spite of elevation an of HCY (HCY>3 nmol/ml) in these
subgroups (Table 2). This result disagreement with Rekha
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Homocysteine level in plasma of Iraqi women
Also, Rekha et al. concluded that IR was common in
PCOS women and was practically more common in obese
PCOS subgroups[16] and this conclusion in line with the
present study. Moreover, the mid test of OGTT provided
an enough information for hyperglycemia in PCOS
women and this suggestion in line with Motala et al., they
performed mid test of OGTT with one year as baseline,
and found the most significant predictive risk factor for
subsequent progression to diabetes was the 90 min plasma
glucose (mid-test level), a surprising finding was that
neither fasting nor 2-hr plasma glucose were significant
[20]
. Certainly, homocysteine level may play an important
role in fertility problem which related to the duration of
infertility, this suggestion agreement with Al- Rubae'[21],
which concluded that hyperhomocysteinemia was
observed in women suffering from infertility, HCY
increased with increase in BMI and obesity in infertile
women, but unfortunately there were no studies illustrated
the role of homocysteine in duration of infertility[21].
Furthermore, non-significant differences were recorded
among PCOS patients and control group may due to small
sample size, in spite of an elevation were assessed in
homocystein and GTT in PCOS group.
[8]. Salehpour, S., Manzor-al-ajdad, O., Samani, E.N.,
Abadi, A. (2011) Evaluation of Homocysteine
Levels in Patients with Polycystic Ovarian
Syndrome. International Journal of Fertility and
Sterility.4 (4): 168-171.
[9]. Refsum, H., Ueland, P.M., Nygard, O. and Vollset,
S.E. (1998) Homocysteine and cardiovascular
disease. Annu Rev Med. 49: 31-62.
[10]. Miller, A.L. and Kelly, G.S. (1997) Homocysteine
Metabolism: Nutritional Modulation and Impact on
Health and Disease. Alt Med Rev. 2(4): 234-254.
[11]. Tarkun, İ., Çetinarslan, B., Cantürk, Z., Türemen E.
(2005) The Plasma Homocysteine Concentrations
and Relationship with Insulin Resistance in Young
Women with Polycystic Ovary Syndrome. Turkish
Journal of Endocrinology and Metabolism.1: 23-28.
[12]. Edmonds, K. (2007) Dewhurst"s Textbook of
Obstetrics and Gynaecology 17th ED, Blackwell
publishing, USA, PP: 736.
[13]. American Diabetes Association (1997) Report of
the Expert Committee on the diagnosis and
Classification of Diabetes Mellitus. Diabetes Care.
20(7): 1183-1197.
[14]. Gambineri, A., Pelusi, C., Vicennati, V., Pagotto,
U. & Pasquali R. (2002) Obesity and the polycystic
ovary syndrome. Int J Obes Relat Metab
Disord. 26(7): 883-896.
[15]. Setji, T.L. and Brown, A.J. (2007) Polycystic ovary
syndrome: Diagnosis and treatment. Am J Med.
120: 128-132.
[16]. Rekha, S., Patel, M.L., Pooja, G., Amita, D.,
Pushplata, S. and Natu, S.M. (2013) Correlation
between elevated homocysteine levels and insulin
resistance in infertile women with or without
polycystic ovary syndrome in North Indian
population. Academic Journal. 5 (3): 116-123.
[17]. Hemati, T., Moghadami-Tabrizi, N., Davari-Tanha,
F., Salmanian, B. and Javadian, P. (2011) High
plasma homocysteine and insulin resistance in
patients with polycystic ovarian syndrome. Iranian
Journal of Reproductive Medicine. 9(3): 223-228.
[18]. Steppan, C.M., Bailey, S.T., Bhat, S., Brown, E.J.,
Banerjee, R.R., Wright, C.M., Patel, H.R., Ahima,
R.S. and Lazar, M.A. (2001) The hormone resistin
links obesity to diabetes. Nature. 409: 307-312.
[19]. Maleedhu, P., Vijayabhaskar, M., Sharma, S.S.B.,
Kodumuri, P.K. and Devi V.D. (2014) Status of
Homocysteine in Polycystic Ovary Syndrome
(PCOS). Journal of Clinical and Diagnostic
Research. 8(2): 31-33.
[20]. Motala, A.A., Omar, M.A.K. and Gouws, E. (1993)
High risk of progression to NIDDM in South
African Indians with impaired glucoses tolerance.
Diabetes; 42: 556-563.
[21]. Al-Rubae', S.H.N. (2012) Studies on hormonal
changes, homocysteine and lipids profile in Iraqi
women with infertility. Al-Taqani. 25(2):107-116.
CONCLUSION
From the results of the present study revealed that the
pathophysiology of PCOS was common multiple causes.
Homocysteine levels associated with insulin resistance and
obesity. Also, it had a relation with duration of infertility.
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